Chapter 5160-31 Medicaid Home and Community Based Services Waiver Portion of the PASSPORT Program

(A) The purpose of this rule is to define the terms used in
Chapter 5160-31 of the Administrative Code governing the
preadmission screening system providingoptions and resources today (PASSPORT)
home and community based services(HCBS) waiver program.

As used in this chapter:

(B) "ADL" means activities of daily living including bathing;
grooming; toileting; dressing; eating; and mobility which refers to bed
mobility, transfer, andlocomotion as defined in rule 5160-3-08 of theAdministrative Code.

(C) "Assessment" means a face-to-face evaluation used to obtain
information about an individual including his or her condition, personal goals
and preferences, functionallimitations, health status and other factors that
are relevant to the authorization andprovision of services. Assessment
information supports the determination that anindividual requires waiver
services as well as the development of the service plan.

(D) "Authorized representative" means a person, eighteen years
of age or older, who is chosen by and acts on behalf of an individual who is
applying for, or receiving,medical assistance. In accordance with rule
5160:1-2- 01.2 of theAdministrative Code, the
individual must provide a written statement naming theauthorized representative
and the duties that the named authorized representativemay perform on the
individual's behalf.

(E) "CDJFS" means a county department
of job and family services.

(F) "C.F.R." means the code of federal
regulations.

(G) "Caregiver" means relatives, friend, and/or
significant others who voluntarilyprovide assistance to the
individual
enrolled in PASSPORT and areresponsible for the
individual's care on a continuing basis.

(H) "Case management" means a set of person centered
activities provided by thePASSPORT administrative agency (PAA) that are
undertaken to ensure that the individual enrolled in PASSPORT
receives appropriate andnecessary services. Under a HCBS waiver, these
activities may include, but are notnecessarily limited to, assessment, service
plan development, service planimplementation and service monitoring as well as
assistance in accessing waiver,state plan, and other services and resources as
needed.

(I) "Certification" means providers are certified by
the Ohio department of aging(ODA) to provide services for PASSPORT as
established in Chapter 173-39 of theAdministrative Code.

(J) "HCBS" or "home and community-based services" means
services furnished under theprovisions set forth in 42 C.F.R. 441 Subpart G
(October 1, 2009) that permitindividuals to live in a home setting rather than
a nursing facility (NF) or hospital.HCBS waiver services are approved by CMS
for specific populations and are nototherwise available under the medicaid
state plan.

(K) "CMS" means the centers for medicare and medicaid services
(CMS), a federalagency that is part of the U.S. department of health and human
services, andadministers the medicaid program and approves home and
community-basedservices waivers.

(L) "FMS" or "financial management service" is a support
provided to waiverparticipants who direct some or all of their waiver services.
In the PASSPORTwaiver, this support is conducted as an administrative activity
through an entityunder contract with the state of Ohio.
When used in conjunction with the self-direction authorities
available to individualsenrolled in PASSPORT, this support
includes operating a payroll service forparticipant-employed workers and making
required payroll withholdings.

(M) "Home first" means the component of the PASSPORT HCBS
waiver program thatoffers priority enrollment in the waiver for certain
individuals in accordance withsection 173.521 of the Revised
Code.

(N) "IADL" means an instrumental activity of daily living as
defined in rule 5160-3-08 of the Administrative Code and includes
shopping; mealpreparation; laundry; community access activities including
telephoning,transportation, legal or financial; and environmental activities
including housecleaning, heavy chores, yard work or maintenance.

(O) "Individual" means a medicaid recipient, a medicaid recipient enrolled in a HCBSprogram, or
person with pending medicaid eligibility who is applying
forHCBS waiver
enrollment ,
or other long-term care services.

(P) "Individual provider" means a
person with a signed medicaid provider agreementwith ODM to provide PASSPORT
services in rule 5160-31-05 of theAdministrative Code, and who meets the
PASSPORT waiver program's conditionsof participation set forth in rule
5160-31-06 of the Administrative Code and who isnot the spouse, parent,
stepparent, and/or legal guardian of the consumer.

(Q) "Keys amendment facility", as found in section
1616(e) of the Social Security Act(as in effect on
January 1, 2014), includes, but is not limited to, aninstitution,
foster home or group living arrangement, including
those licensed bythe state, in which a significant number of recipients
of supplemental securityincome benefits are residing or are likely to reside.

(R) "Level of care" or
"LOC" means the designation
describing a person'sfunctional levels and nursing needs pursuant to the
criteria set forth in rules 5160-3-05, 5160-3-06,
5160-3-07 and 5160-3-08 of the Administrative
Code.

(S) "NF" means a nursing facility as defined in
section 5165.01 of the
RevisedCode.

(T) "ODA" means the Ohio department of aging.

(U) " ODM" means the Ohio department of
medicaid.

(V) "PAA" means PASSPORT administrative agency.

(W) "PASSPORT" or "PASSPORT HCBS waiver program" means
an HCBS waiverprogram that serves individuals who are aged sixty and over who
have a LOCrequired for placement in a NF if the waiver program were not
available, and meetthe PASSPORT eligibility criteria and enrollment
requirements in Chapter 5160-31 of the Administrative Code.

(X) "Region" means the geographic area in which a PAA
administers thePASSPORT program.

(Y) "Service plan" means a written, person centered
plan between the individual, the individual's case manager at the PAA and,
asapplicable, the individual's caregiver(s). The service plan specifies
theservices that are provided to the individual,
regardless of funding source,to address the individual's care needs as identified in the individual's assessment.

(Z) "Subregion" means a geographic area located within
a PAA region for the purposeof establishing PASSPORT unit rates as set forth in
rule 5160-31-07of the Administrative Code.

(AA) "Waiver service provider" means an agency or
person with a signed medicaidprovider agreement with ODM to provide
HCBS waiver services, and whomeets the PASSPORT conditions of participation set
forth in rule 5160-31-06 of the Administrative Code.

(A)
: To be eligible for the medicaid-component
of the pre-admission screening system providing options and resources today
(PASSPORT) program, an individual must meet all of the following
requirements:

(1)
The individual must
have been determined eligible for medicaid in accordance with
Chapters 5160:1-1 to
5160:1-5 of the
Administrative Code.

(2)
The waiver
service cost of the twelve-month service plan does not exceed the individual
cost limit. The individual cost limit is equal to fourteen thousand and seven
hundred dollars per month for waiver services.

(a)
If the Ohio Department of Aging's (ODA) designee
determines that the applicant's waiver service needs cannot be met within the
individual cost limit, the individual shall not be enrolled.

(b)
Once enrolled in PASSPORT, additional
waiver services may not be authorized in excess of the fourteen thousand and
seven hundred dollars per month individual cost limit. When a change in
condition occurs that necessitates the provision of additional waiver services,
referrals to other community services, including institutional services, will
be explored.

(c)
If the
individual's waiver service needs exceed the individual cost limit of fourteen
thousand seven hundred dollars per month, the individual shall be disenrolled
from the waiver.

(3)
The
needed services are not readily available through another source at the level
required to allow the individual to live in the community.

(4)
The individual agrees to participate in
PASSPORT and while enrolled in PASSPORT, shall
not be simultaneously enrolled in the state-funded
component of the PASSPORT program, the state-funded component of the assisted
living program, another medicaid home and
community-based program, the residential state supplement (RSS)
program, or the program of all inclusive care for the elderly (PACE) while
enrolled in PASSPORT.

(5)
The
individual's health related needs can be safely met in a home setting as
determined by the ODA's designee.

(6)
The individual
will participate in the development of a person-centered services plan in
accordance with the process and requirements set forth in rule 5160-44-02 of
the Administrative Code.

(7)
,
The
individual's attending physician must approve that the services are
appropriate to meet the individual's needs. The physician's approval may be
either verbal or written. If the approval is verbal, written approval must be
obtained within thirty days of the enrollment date. ODA's designee
shall be responsible for obtaining the physician's approval.

(8)
While receiving PASSPORT, the individual must reside in
a setting that possesses the home and community-based setting characteristics
set forth in rule 5160-44-01 of the Administrative Code and not be a
resident of either a Keys amendment facility, a hospital or a nursing facility
(NF) as defined in rule
5160-31-02 of the Administrative
Code. For purposes of this rule, a resident of a Keys amendment facility is an
individual who receives services from the facility and is not a family member
of the owner or operator of the facility.

(10)
The individual
must be determined to meet the criteria for an intermediate or skilled level of
care in accordance with rule
5160-3-08 of the Administrative
Code and, in the absence of PASSPORT, would require NF services as defined in
42 C.F.R.
440.40 (as in effect on October 1, 2014).

(11)
PASSPORT has not reached the centers for medicare and medicaid services
(CMS)-authorized limit on the number of individuals who may enroll on the
waiver during the current year.

(12)
The individual
must require the provision of at least one waiver service on a monthly basis as
documented in the individual's approved person-centered
service plan.

(B)
If, at any time, the individual fails or ceases to meet any of the eligibility
requirements identified in this rule, the individual
shall be denied or disenrolled from PASSPORT. In such instances, the individual
shall be notified of his or her hearing rights in accordance with division
5101:6 of the Administrative Code.

(A) The Ohio department of aging (ODA) is responsible for the
daily operation of the PASSPORT home and community based services (HCBS)
waiver. ODA willoperate this waiver pursuant to an interagency agreement with
the Ohio departmentof medicaid in accordance with
sections 5162.35 and
5166.21 of the Revised
Code. ODA will establishprocesses and procedures to enroll individuals on this
waiver.

(B) Individuals who wish to enroll in PASSPORT must have a
medicaid eligibility determination made by the county department of job and
family services (CDJFS)and an assessment of PASSPORT waiver eligibility made by
the PASSPORTadministering agency (PAA). The individual may contact either the
CDJFS or thePAA to start the enrollment process and the two agencies shall
coordinateprocessing the request for enrollment into the PASSPORT HCBS waiver
program:

(1) Individuals initially contacting the CDJFS will complete
the JFS 07200 "Request for Cash, Food , and Medical Assistance" (rev. 12/2012) and
the JFS 02399 "Request for Medicaid Home andCommunity Based Services" (rev.
5/2013)
in accordance with rules 5160:1-2- 01.2 and 5160:1-2-
01.6 of theAdministrative Code. The CDJFS will notify the PAA of the
individual'sapplication for waiver services. The PAA will initiate contact with
theindividual to complete the enrollment process.

(2) Individuals initially contacting the PAA will receive an
in-person assessment to determine eligibility for the PASSPORT HCBS waiver
program. The PAAmay assist the individual in applying for medicaid if not
already initiated bycompleting the JFS 07200 and JFS 02399.

(C) If the individual has been determined eligible and a waiver
slot is available, the individual shall be enrolled in accordance with
the PASSPORT HCBSwaiver program's home first component, if applicable, and rule
173-42-03 of theAdministrative
Code.

(D) The PAA shall make the determination of PASSPORT
eligibility using the criteria set forth in rule 5160-31-03 of the Administrative Code. The PAAshall
notify the CDJFS of the results of the PASSPORT eligibility
determination.

(E) Any applicant for PASSPORT HCBS waiver program services is
entitled to notice and hearing rights as set forth in section
5101.35 of the Revised Code and
division5101:6 of the Administrative Code.

(A)
The purpose of this rule is to establish
the services covered by the pre-admission screening system providing options
and resources today (PASSPORT) home and community based services (HCBS) wavier
program.

(B)
The PASSPORT HCBS
waiver program benefit package is limited to the following services:

(1)
Adult day services as set forth in rule
173-39-02.1 of the Administrative Code;

(2)
Alternative meal services as set forth in
rule 173-39-02.2 of the Administrative Code;

(3)
Choices home care attendant services as
set forth in rule 173-39-02.4 of the Administrative Code;

(4)
Chore services as set forth in rule
173-39-02.5 of the Administrative Code;

(5)
Community transition services as set
forth in rule 173-39-02.17 of the Administrative Code;

(6)
Emergency response system services as set
forth in rule 173-39-02.6 of the Administrative Code;

(7)
Enhanced community living services as set
forth in rule 173-39-02.20 of the Administrative Code;

(8)
Homemaker services as set forth in rule
173-39-02.8 of the Administrative Code;

(9)
Home care
attendant services as set forth in rule 173-39-02.24 of the Administrative
Code;

(10)
Home delivered
meal services as set forth in rule 173-39-02.14 of the Administrative
Code;

(11)
Home medical
equipment and supplies services as set forth in rule 173-39-02.7 of the
Administrative Code;

(12)
Independent living assistance services as set
forth in rule 173-39-02.15 of the Administrative Code;

(13)
Minor home modification, maintenance and repair
services as set forth in rule 173-39-02.9 of the Administrative Code;

(14)
Non-medical transportation services as set forth
in rule 173-39-02.18 of the Administrative Code;

(15)
Nutrition consultation services as set forth in
rule 173-39-02.10 of the Administrative Code;

(16)
Out-of-home
respite services as set forth in rule 173-39-02.23 of the Administrative
Code;

(17)
Personal care
services as set forth in rule 173-39-02.11 of the Administrative
Code;

(18)
Pest control
services as set forth in rule 173-39-02.3 of the Administrative Code;

(19)
Social work counseling services as set forth in
rule 173-39-02.12 of the Administrative Code;

(20)
Transportation services as set forth in rule
173-39-02.13 of the Administrative Code ; and

(21)
Waiver nursing
services as set forth in rule 173-39-02.22 of the Administrative
Code.

(C)
Services
shall be delivered by providers in a manner that is consistent with the
individual's service plan as documented in the PASSPORT information management
system (PIMS).

(D)
If an individual
enrolled on PASSPORT is also a participant in the helping ohioans move,
expanding (HOME) choice demonstration program in accordance with Chapter
5160-51 of the Administrative Code, the individual may, at the individual's
discretion, use the HOME choice community transitions service in lieu of, but
not in addition to, the community transition service available through the
PASSPORT waiver program.

(E)
If an
individual receives enhanced community living services, per the federally
approved waiver, the consumer may not receive either personal care or homemaker
services available through the PASSPORT waiver program.

(F)
In accordance with the federally approved
PASSPORT waiver the services identified in this paragraph are subject to
employer and/or budget authority if elected by the individual. Services are to
be furnished in accordance with the requirements in paragraph (B) of this rule:

(1)
The following services are subject to
employer authority, which includes but is not limited to, the ability to hire,
fire, and train employees:

(G)
An individual who elects to
self-direct any of the services provided in paragraph (F) of this rule shall be
assessed by their case manager to determine the individual's ability to
self-direct their services as set forth in rule
173-42-06 of the Administrative
Code.

(1)
If an individual demonstrates the
ability to self-direct their care the case manager may initiate the orientation
process to familiarize the individual with the self-direction of services
including the role of the financial management service (FMS).

(2)
If the individual is unable to
demonstrate the ability to self-direct his or her care and to assume the
responsibilities associated with the self-direction authorities in paragraph
(F) of this rule, the individual may choose an authorized representative to act
on his or her behalf.

(3)
If no
authorized representative is available, the case manager will assist the
individual with obtaining services through ODA-certified long-term care agency
providers.

(H)
If an
individual who is seeking to self-direct his or her care chooses an authorized
representative to act on his or her behalf in accordance with paragraph (G)(2)
of this rule, the authorized representative shall not simultaneously serve as
the consumer's authorized representative and the consumer's provider.

(A)
The purpose
of this rule is to establish the conditions under which providers are able to
participate in the preadmission screening system providing options and
resources today (PASSPORT) home and community based services (HCBS) waiver
program.

(B)
In order to obtain a
medicaid provider agreement to be a PASSPORT provider furnishing services in rule
5160-31-05 of the Administrative
Code the provider shall be certified
by the Ohio department of aging (ODA) or its designee in accordance with the
provisions of Chapter 173-39 of the Administrative Code.

(C)
Individuals enrolled in the PASSPORT HCBS waiver
shall be given a free choice of qualified providers in accordance with rule
173-42-06 of the Administrative
Code.

The purpose of this rule is to describe the methods used to
determine provider rates for the pre-admission
screening system providing options and resources today (PASSPORT) home and
community based services (HCBS) medicaid waiver program.

(A)
Rates determined under this rule shall
not exceed the maximum reimbursement rate for PASSPORT services in appendix A
to rule 5160-1-06.1 of the Administrative Code. Payment for PASSPORT HCBS
waiver services constitutes payment in full and may not be construed as a
partial payment when the payment amount is less than the provider's usual and
customary charge. The provider may not bill the individual for any difference
between the medicaid payment and the provider's charge or request the
individual to share in the cost through a co-payment or other similar
charge.

(B)
PASSPORT reimbursement
rates are established for the services in rule
5160-31-05 of the Administrative
Code under the following categories:

(C)
Rates set within the
categories in paragraph (B) of this rule may be:

(1)
Participant-directed, in which the
individual or their designated authorized representative, who is acting on the
individual's behalf, may negotiate the reimbursement
rate for services furnished by providers as specified in paragraphs (D)(3),
(E)(3), (G)(4), and (H) of this rule.

(2)
Statewide, in which the state establishes
a rate that is used on a statewide basis to reimburse for services specified in
paragraph (F) of this rule.

(3)
Regional, in which the state establishes a regional reimbursement rate for
services specified in paragraph (G) of this rule. The regions in which
applicable rates are calculated shall be designated by ODA.

(a)
The regional rate for each service shall
be the weighted average rate paid in the region using cost and unit data either
from the most recently completed state fiscal year or the most recent twelve
calendar months for which complete data is available, whichever is
later.

(b)
ODA or its designee
shall enter into a contract with providers in each region. The contract shall
do all of the following:

(i)
No provider
shall have a contract rate that exceeds the rate for that service as
established in rule 5160-1-06.1 of the Administrative Code.

(ii)
If the state recalculates regional rates
for the services in paragraph (G) of this rule, certified providers may either
accept the new regional rate or continue to be reimbursed at the rate paid for
services prior to the calculation of the regional rate.

(iii)
Providers who are certified after the
regional rate is established shall have a contract rate less than or equal to
the regional rate.

(4)
Group rates, in which a provider that is
furnishing certain services to more than one individual enrolled on PASSPORT is
reimbursed at a rate that is seventy-five per cent of the reimbursement rate
the provider would be paid for furnishing PASSPORT services as specified in
paragraphs (D)(2), (F)(2), (G)(2), and (G)(3) of this rule.

(D)
For the services listed in
this paragraph, a per job bid rate shall be negotiated between the provider and
the individual's case manager.

(2)
Transportation and non-medical
transportation services rendered simultaneously by the same provider to more
than one individual enrolled in PASSPORT residing in the same household and
traveling in the same vehicle to the same destination shall be reimbursed using
a group rate that is equal to seventy-five per cent of the provider's per job
bid rate. This applies to any combination of transportation and/or non-medical
transportation services.

(3)
Minor
home modification and pest control services may be participant directed
services in which the individual enrolled on PASSPORT or their authorized
representative, acting on the individual's behalf, may negotiate reimbursement
rates.

(a)
The negotiated rate shall be
reviewed by the individual's case manager and reflected on the
individual's service plan prior to service
delivery.

(b)
Should the individual
choose not to negotiate a rate of reimbursement the service shall be reimbursed
at a rate proposed by the provider and accepted by the consumer and the
consumer's case manager. The accepted rate shall be reflected on the consumer's
service plan.

(E)
A per item rate shall be determined for
home medical equipment and supplies service.

(1)
The cost of the item shall not exceed the
medicaid state plan rate.

(2)
The
cost of an item that does not have an established medicaid rate shall be
reimbursed at a per item bid rate submitted and agreed to in writing by the
PASSPORT administrative agency (PAA) prior to delivery of the item.

(3)
Home medical equipment and supplies
services may be participant directed in which the individual enrolled on
PASSPORT or the authorized representative, acting on the
individual's behalf, may negotiate reimbursement
rates.

(a)
The negotiated rate shall be
reviewed by the individual's case manager and reflected on the
individual's service plan prior to service
delivery.

(b)
Should the individual
choose not to negotiate a rate of reimbursement the service shall be reimbursed
at a rate proposed by the provider and accepted by the consumer and the
consumer's case manager. The accepted rate shall be reflected on the consumer's
service plan.

(F)
The Ohio department of aging (ODA) shall
establish unit rates for the services listed in this paragraph. No service
shall have both a regional and statewide rate set pursuant to this rule.

(1)
Statewide rates shall be established and
used for the following services:

(2)
The services in paragraphs (F)(1)(d), (F)(1)(f),
and(F)(1)(g) of this rule, when rendered
during the same visit to more than
one but less than four PASSPORT consumers in the same household, as identified
in the consumers' service plans, shall be reimbursed using a group rate equal
to one hundred per cent of the provider's per unit rate set in accordance with
paragraph (C) of this rule for one PASSPORT consumer. The provider shall be
reimbursed seventy-five per cent of the provider's per unit rate for each
subsequent PASSPORT consumer in the household receiving services during the
visit.

(G)
ODA shall
establish regional unit rates for the services listed in this paragraph
pursuant to the methodology in paragraph (C)(3) of this rule. No service,
except personal care services provided under paragraph (F)(1)(f) of this rule,
shall have both a regional and statewide rate set pursuant to this rule.

(2)
Adult day
service transportation services rendered simultaneously by the same provider to
more than one consumer residing in the same household and traveling in the same
vehicle to the same destination shall be reimbursed using a group rate equal to
seventy-five per cent of the provider's regional unit rate.

(3)
Personal care services, except personal
care services provided under paragraph (F) of this rule, that are rendered
during the same visit by the same provider to more than one but less than four
PASSPORT consumers in the same household, as identified in the consumers'
service plans, shall be reimbursed using a group rate equal to one hundred per
cent of the provider's regional per unit rate set in accordance with paragraph
(C) of this rule for one PASSPORT consumer. The provider shall be reimbursed
seventy-five per cent of their regional per unit rate for each subsequent
PASSPORT consumer in the household receiving services during the
visit.

(4)
Homemaker services may
be participant directed services in which the individual enrolled on PASSPORT
or their authorized representative, acting on the individual's behalf, may negotiate reimbursement
rates.

(a)
The negotiated rate shall be
reviewed by the individual's case manager and reflected on the
individual's service plan prior to service
delivery.

(b)
Should the individual
choose not to negotiate a rate of reimbursement the service shall be reimbursed
in accordance with paragraph (G) of this rule. The accepted rate shall be
reflected on the consumer's service plan.

(H)
The services in this paragraph are
participant directed and the individual may negotiate unit rates with
providers.

(2)
The consumer shall have in effect, before choices home care attendant services
are delivered, a signed agreement with each ODA-certified consumer-directed
individual provider delivering services to the consumer. The agreement shall:

(c)
Base rates on the units of service as set
forth in Chapter 173-39 of the Administrative Code;

(d)
Be signed by the choices HCBS waiver
program participant and the HCBS provider.

(3)
The rates negotiated by the choices HCBS
waiver consumer with providers of services in this paragraph shall not exceed
the maximum allowed per unit of service as specified in appendix A to rule
5160-1-06.1 of the Administrative Code. The negotiated rate shall be reviewed
by the consumer's case manager and reflected on the consumer's service plan
prior to service delivery.

(4)
Should the consumer choose not to negotiate a rate of reimbursement for any of
the services in this paragraph, the service shall be reimbursed at a rate
proposed by the provider and accepted by the consumer and the consumer's case
manager. The accepted rate shall be reflected on the consumer's service
plan.

(I)
The Ohio
department of medicaid, or its designee, shall evaluate unit rates within two
years of the effective date of this rule and every two years thereafter.